Provider Demographics
NPI:1275652497
Name:NAM, DOUGLAS K (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:K
Last Name:NAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13100 E 136TH ST
Practice Address - Street 2:SUITE 3000
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9817
Practice Address - Country:US
Practice Address - Phone:317-678-3900
Practice Address - Fax:317-678-3910
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01069647A207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000790143OtherANTHEM BCBS PIN
IN201032650Medicaid
INP01163005Medicare PIN
IN201032650Medicaid
INM400053211Medicare PIN